Page 15 - PWH.19 Employee Benefits

ur deductible has been met, if a deductible applies.

What You Will Pay Limitations, Exceptions, & Other
vider Non-Network Provider Important Information
least) (You will pay the most)

ce 30% coinsurance --------none--------

ce 30% coinsurance --------none--------

You may have to pay for services that

aren't preventive. Ask your provider if

30% coinsurance the services needed are preventive.

Then check what your plan will pay

for.

ce 30% coinsurance --------none--------

ce 30% coinsurance --------none--------
$70/prescription or 50% *See Prescription Drug section
(retail coinsurance, whichever is
ery)
greater (retail)
then $70/prescription or 50%
retail) coinsurance, whichever is

retail) greater (retail)
ption $70/prescription or 50%
y) coinsurance, whichever is
up to
(retail) greater (retail)
ce up to
(home $70/prescription or 50%
coinsurance, whichever is

greater (retail)

ce 30% coinsurance --------none--------

ce 30% coinsurance --------none--------

ce Covered as In-Network --------none--------

ce Covered as In-Network --------none--------

ce 30% coinsurance --------none--------

ce 30% coinsurance Physical medicine and rehabilitation
services (including day rehabilitation

document at https://eoc.anthem.com/eocdps/fi.

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